Retreat inspection finds need for prompt fix

The Brattleboro Retreat has struggled recently to meet federal standards and nearly lost its certification and funding. Here Robert Simpson, president and CEO, stands in front of the building renovated with state funds to create a unit to treat high-level psychiatric patients.
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When inspectors departed the Brattleboro Retreat on Oct. 1 after an unannounced visit, they informed officials at the private psychiatric hospital they had found conditions that "posed an immediate jeopardy to the health and safety of patients."

Inspectors made the finding because they said the hospital had failed to respond sufficiently to a widespread safety risk following an incident in which a patient considered a high safety risk showed staff the potential suicide hazard posed by an elastic bandage. The bandage material was being used throughout the hospital.

The inspectors also told Retreat officials of their concerns about staff failing to follow protocol that resulted in a near drowning and about a runaway patient.

Immediate jeopardy was a much more serious finding from the visit by regulators than Retreat officials communicated Oct. 3 when they made public that the hospital had failed another inspection. The focus Oct. 3 was the verbal agreement the Retreat, with help from the state, had negotiated with the federal Centers for Medicare and Medicaid Services to avert loss of its certification and funding.

"The new events haven't given any confidence to me that the Retreat wants to be transparent about problems," complained Rep. Anne Donahue, R-Norwich. Donahue is a long-time watchdog of the mental health system and a member of the Legislature's Mental Health Oversight Committee.

Konstantin von Krusenstiern, vice president of development at the Retreat, countered, "We notified DMH immediately when there was an immediate jeopardy finding and then notified them a few hours later when immediate jeopardy was lifted." The hospital removed the elastic bandages from the hospital.

The new information about the inspection findings came out in a memorandum the Retreat submitted Thursday to the commissioner of the Department of Mental Health (DMH) and to legislators. The actual inspection report provided more details. The Retreat provided the report to the state on Oct. 10 and it became available online earlier this week.

The Retreat was already "on probation" because of shortcomings identified during two previous inspections. As a result, it faced potential loss of certification and federal funding for patients on Medicaid beginning Oct. 6.

The unannounced inspection from Sept. 29 through Oct. 1 was to determine if the hospital had remedied all the previous deficiencies. Instead, inspectors found new, more serious problems.

The problems described in the Thursday memorandum and the newly posted CMS report of the inspections included:

• A patient placed an elastic bandage around his/her neck in front of staff on Sept. 29. While the "spandage" was removed and the patient was unharmed, the inspectors said the availability of this kind of elastic bandage posed a danger throughout the hospital. They also said the hospital had failed to recognize the danger — until inspectors demonstrated it to staff.

• A 16-year-old patient attempted to drown in a bath on Sept. 22 because a staff member failed to stay in the room, choosing instead to stand outside. Staff intervened in time, but the inspectors criticized the Retreat for an insufficient response. The criticism prompted the Retreat to revise its one-to-one staffing practice.

• A patient slipped away while being escorted along a nonsecured hallway on Sept. 23 and was later returned in handcuffs by local police. The CMS report suggests the staff should have anticipated the patient might try to run away because the person had already tried and also voiced suspicions about staff. The Retreat's summary of the incident focused on the staff's failure to ask police to immediately remove handcuffs once the patient was inside the hospital.

Faced with another failed inspection despite having corrected the immediate jeopardy, Retreat officials asked for help from Gov. Peter Shumlin and state mental health officials. During talks the day after the inspectors departed the Retreat, CMS offered the hospital a rarely used option: a special oversight agreement.

Under this arrangement, CMS would continue federal funding and certification for a month past its previous Oct. 6 cut-off date to allow the hospital to work out the details of a Systems Improvement Agreement with federal regulators.

The hospital also had to write a plan to get to the root causes for the problems identified in the most recent inspection and make permanent corrections. The Retreat memorandum said it submitted its correction plan Thursday.

CMS must approve the details of the improvement agreement and the correction plan by Nov. 1. The agreement is expected to run two years, with the Retreat's certification and funding continuing during that period.

The improvement agreement will require the Retreat to hire an independent expert to help it identify and address shortcomings that put it out of compliance with CMS requirements.

State officials and lawmakers have welcomed the increased oversight that the CMS improvement agreement will bring.

"In the long run this will be beneficial for the Retreat in getting back its credibility with CMS," Mental Health Commissioner Paul Dupre said. Noting inspectors' repeated findings of deficiencies at the Retreat in the past year, Dupre said, "Anyone who gets under the eye of the regulators, there is a level of confidence that might start eroding."

Rep. Donahue said she thinks the state should have been monitoring care at the Retreat more aggressively once the hospital started having problems with CMS.

"Since we aren't in a position to say we are going to suspend sending patients there, then we better be in a place where we are watching incredibly closely what is going on," Donahue said. The state sends adults and children to the Retreat. "We have an obligation to make sure it is quality, safe care."

Rep. Ann Pugh of South Burlington, who heads the Mental Health Oversight Committee, said she would like to see the Department of Mental Health respond to the crisis at the Retreat with a broad look at what improvements need to be made throughout the mental health system. "This goes beyond the Retreat," she said.

"It is up to us to make sure the Retreat along with all the providers in the system meet the highest standard," Pugh said. "We need to remain vigilant."